Peroral endoscopic myotomy (POEM) for achalasia (sometimes also referred as E-POEM to distinguish it from its offshoots such as G-POEM for gastroparesis or Z-POEM for Zenker's diverticula) is the newest treatment modality but has already been well validated as a standard intervention for esophageal achalasia. POEM was conceived as a natural orifice transluminal endoscopic surgery (NOTES) procedure with an incisionless, endoscopic approach to myotomy. It matches or exceeds the efficacy of its surgical counterpart, the laparoscopic Heller myotomy, with superiority for type III (spastic) achalasia. However, there are issues, especially regarding GERD after POEM that will likely result in further refinements of technique and post-procedural care. We will summarize the current status of POEM including description of technique variations and review of comparative data vis a vis Heller myotomy (HM) and pneumatic dilation (PD) and we will delve into some of the seminal issues around GERD assessment, management and prevention.